Pawsitively 4 Pink Financial Assistance Application

Pawsitively 4 Pink's Power to Thrive Program

Please complete this form to apply for financial assistance. All information will be kept confidential.
Pawsitively 4 Pink primarily serves low-income women and families experiencing financial hardship due to breast cancer treatment. Eligibility is determined using household size, income, and individual circumstances, with applicants generally falling at or below 250% of the Federal Poverty Level guidelines. P4P recognizes the high cost of living in Massachusetts and the significant loss of income many women experience during treatment, and strives to provide compassionate, individualized support to those facing financial instability during and after cancer care.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Age
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Please describe your current financial situation and why you are seeking assistance.
Demographic Information Race/Ethnicity
How did you hear about Pawsitively 4 Pink?
Diagnosis & Treatment Information
Have you received any other financial assistance in the last year?
If yes, who provided the assistance?
If yes, how much was the assistance?
Type of Diagnosis
Date Diagnosed

MonthDayYear
Date
Current Treatment Status
Treatment Facility / Provider
Household Information
Marital Status
Number of Adults in Household
Number of Children in Household
Children ages
Employment & Income
Have you experienced a loss of income due to treatment?
Current Employment Status
Monthly Household Incom
Name of company that you work for
How would you describe your current stress level related to finances?
Pawsitively 4 Pink Wellness & Support Survey

Your answers help us better understand how breast cancer treatment is affecting your daily life and well-being. This information also helps us measure the impact of our support services.
How emotionally supported do you currently feel?
How would you rate your overall mental health right now?
How would you rate your current physical well-being?
How often does financial stress impact your emotional health?
How difficult has it been to manage daily living expenses during treatment?
How hopeful do you currently feel about your situation?
How often are you able to focus on your healing and recovery without financial worry?
How connected do you feel to support systems (family, friends, community, organizations)?
What is your biggest concern right now?
Assistance Requested
Required Documentation Checklist
Consent & Signature
I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that submitting this application does not guarantee assistance.
Applicant Signature

Please sign above.
Date

MonthDayYear
Date
Pawsitively 4 Pink strives to review all applications and respond within approximately 14 days. While we wish we could assist every woman who applies, due to financial limitations and our commitment to providing meaningful levels of support to those we are able to serve, assistance cannot be guaranteed for all applicants.
Should be Empty:

Pawsitively 4 Pink's Power to Thrive Program

Diagnosis & Treatment Information

Household Information

Employment & Income

Pawsitively 4 Pink Wellness & Support Survey

Consent & Signature